Mental health for all - by all

Transcription

1 Mental health for all - by all Vikram Patel Professor of International Mental Health Wellcome Trust Senior Research Fellow in Clinical Science London School of Hygiene & Tropical Medicine, UK Sangath, India Public Health Foundation of India 1

2 Courtesy: Abhay Bang, SEARCH, India 2

3 3

4 4

5 5

6 Relevance to global mental health? 6

7 an area for study, research and practice that places priority on improving mental health and achieving equity in mental health for all people worldwide 7

8 Suicide is a leading cause of death of young people globally Patel et al, Lancet

9 Depression is a LEADING CAUSE of the global burden of disease Mental illnesses account for 15% of the global burden of disease About 500 MILLION people on our planet suffer from a mental illness 9

10 People with mental disorders die younger 1/28/

11 November

12 12 7 JULY 2011 VOL 475 NATURE

13 Synthesizing evidence on what works 13

14 The treatment gap is over 50% in all countries Reaches an astonishing 90% in low income countries 14

15 Low political will Resistance to decentralization Difficulties to integration of mental health in primary care Lack of public mental health leadership Weak human resource capacity 15

16 India s population 1.2 billion psychiatrists 3000 psychiatrists 16

17 17

18 Lay health workers delivering group Interpersonal therapy for depression in rural Uganda (Bolton et al, JAMA 2005, 2007) 18

19 Lady health visitors using CBT to treat postnatal depression in rural Pakistan (Rahman et al, Lancet 2008) 19

20 The MANAS trial for depression and anxiety disorders (Patel et al, Lancet 2010) 20

21 100% 95% 90% Recovery Rate From Depression 80% 70% 60% 50% 40% 30% 45% 73% 41% 70% 50% Intervention arm Control arm 20% 10% 0% Bolton et al, JAMA 2003 Uganda Rahman et al, Lancet 2008 Pakistan Patel et al, Br J Psych 2012 India

22 Relevance to trauma Trauma is a major determinant of several mental health problems, including depressive and anxiety disorders The burden of trauma related life experiences is arguably greater in LMIC, not least in the context of humanitarian crises Is there evidence specifically for trauma related disorders? 22

23 23

24 SUNDAR Simplify the message UNpack the treatment Deliver it where people are Affordable and available human resources Reallocation of specialists to train and supervise 24

25 Old wine in a new bottle? 25

26 26

27 27

28

29 Findings 5 trials comparing paraprofessionals with control condition (n=220) SMD 0.34 (0.13 to 0.88) in favour of paraprofessionals 5 trials comparing paraprofessionals with professionals (n=106) SMD 0.09 (-0.23 to 0.4) 29

30 Concerns Dismisses role of specialists Specialists play critically important roles, for e.g. in developing the treatments and building capacity Dumbs down mental health care It expands the range of interventions to achieve a larger coverage of services to address unmet needs Subversive Practical avatar of the idea that mental health is too important to be left to professionals alone 30

31 Challenges Limited efficacy of some task-shifting, e.g. for severe mental health problems Lack of political will and professional support Practical barriers to integration in routine care No evidence for task-shifting for diagnosis No evidence for task-shifting for pharmacotherapy 31

32 What s in store for me Developing culturally appropriate treatments for severe depression and harmful drinking (PREMIUM) For autism (PASS) for delivery by peers for maternal depression (SHARE) Scaling up task-sharing within functioning health systems In district health systems in five countries (PRIME) In rural communities in India (VISHRAM) District Mental Health Program (Government of India) Building competency in PTs through e-learning platforms 32

33 Why task-shifting is SUNDAR Utilitarian Equitable Acceptable Empowering 33

34 Anjana s story At first I was known as Ambadas s wife. But, now I am well known all over my village as Anjana - Health worker. The villagers have selected me for various posts on many organizations. I have been respected as I am the health worker of Search organization. I have even given talks about my work at Delhi and Ranchi. Also I have got an opportunity to travel by airplane only due to my employment as a health worker. 34

35 35

36 36

37 37

38 The Movement for Global Mental Health aims to improve services for people with mental disorders worldwide

39 Acknowledgements The Wellcome Trust DFID NIMH Sir Dorabji Tata Trust MacArthur Foundation Autism Speaks 39

40 40